Introduction

This article provides healthcare providers with a step-by-step guide on how to successfully complete the NRP skills session as well as the E-sims portion of the NRP exam. The How to do NRP Skills Step by Step article does not reflect the upcoming Neonatal Resuscitation 8th edition guidelines.

Initial Neonatal Resuscitation is all about being ready. If you are not ready, your resuscitation will be inefficient. This is why it’s essential to have your American Academy of Pediatrics NRP certification. We highly recommend that our students purchase the AAP Neonatal Resuscitation Program NRP 7th Edition Textbook prior to taking your exam and NRP skills. 

Preparation

Preparation for a delivery is a must. You certainly don’t want a doctor standing beside you “blowing wind tunnels” waiting for you to rummage through the drawers looking for supplies!

• All equipment and supplies needed for resuscitation are referenced in the NRP textbook. To view a quick summary view our blog on Preparing for the Neonatal Resuscitation Program NRP Skills.

• All equipment is usually stored in the drawers of the radiant warmer.
  • You just need to know which drawer!!
• All steps of resuscitation must be performed quickly and efficiently.

All healthcare providers who work in Obstetrics must be aware of the conditions that may cause an infant to require neonatal resuscitation.

Click here to view our blog on anticipating neonatal resuscitation. In addition, healthcare providers must be aware on how to prepare the proper equipment needed to assist an apneic infant or neonates requiring chest compression’s and epinephrine.

The initial steps of neonatal resuscitation include drying, stimulation, and perhaps suctioning.

• You must dry the infant with a towel then throw the towel away from the infant.
  • If you leave a wet towel on the infant, the infant will get cold and your resuscitation will be inefficient.
  • Next, you must stimulate gently. There is no need to stimulate vigorously.
  • In addition, you are required to suction the mouth and then the nose if there are copious secretions. If you suction the nose before the mouth your resuscitation will be inefficient.
  • In fact, suctioning the nose first causes the infant to snort and pull secretions from his/her mouth into the lung and your resuscitation will be inefficient.

If the infant is apneic or gasping, you must provide positive pressure ventilation (PPV) that causes the chest to rise and fall.

• Bag Mask ventilate at a rate of 1 breath every 3 to 5 seconds.
• Most importantly, if there is no rise and fall of the chest with Positive Pressure Ventilation your resuscitation will be inefficient.
• If there is no rise and fall of the chest, you must:
  • Mask Reposition
  • Suction the mouth then the nose.
  • Open the mouth
  • Increase the pressure.
  • Maintain or secure the airway
  • MR SOPA

What’s the point of providing positive pressure ventilation if air does not enter the lungs!

• Do not provide PPV too rapidly – slow down. For instance, I like to say “bag the baby” during PPV so that I don’t deliver PPV too rapidly. 
  • If you “bag the baby” too rapidly, you will cause a pneumothorax and your resuscitation will be compromised.
• Moreover, do not provide PPV too aggressively with too much pressure.
  • To much pressure will cause a pneumothorax and your resuscitation will be compromised.

Have someone place a pulse oximeter on the right hand as soon as possible.

• It takes time to place the pulse oximeter and if it’s not attached as soon as possible, your resuscitation will be inefficient.
• If you place the pulse oximeter any other place than the right hand, you will get post-ductal saturation and not preductile saturation. Thus, your resuscitation will be inefficient.
• You want to know the saturation of the blood as it initially enters the heart and not what comes out of the heart.

Have someone get a heart rate using your stethoscope.

• If you palpate the umbilical cord for the pulse you may be mistaken and your resuscitation will be inefficient.
• You must calculate the heart rate in 6 seconds and multiply that number by 10.
• For example if you auscultate or palpate 10 beats in 6 seconds multiply 10 x 10. The correct answer is 100 bpm.

If the heart rate is less than 60 bpm, you must call for intubation.

• Keep providing PPV until the doctor is ready to establish an advanced airway.
• If you begin chest compression’s before intubation, your resuscitation will be inefficient. The reason being newborns have poor ventilation and not poor circulation.
• After the Intubationist arrives and takes over the bag/mask, move to the left of the Intubationist and prepare the instruments.
• The laryngoscope blade size is 0 for the preterm infant and 1 for the term infant.
  • If you have the wrong size laryngoscope, your intubationist will have difficulty intubating and your resuscitation will be inefficient
• Next check the light source. If you do not have a light source your resuscitation will be inefficient.
• Put the blade in a locked position.
• The Intubationist will lower his/her head to view the glottis. At this point He/she is no longer looking at you.
• You must hand the laryngoscope into the LEFT hand of the Intubationist. If you hand the laryngoscope to his right hand, the light source of the laryngoscope will be directed outward and the intubationist will not be able to view the glottis and your resuscitation will be inefficient.

You must have the right size ET tube for the gestational age of the infant.

• A 25 weeker requires a 2.5 ET tube
• A 30 weeker requires a 3.0 ET tube
• A 35 weeker requires a 3.5 ET tube
• A 40 weeker requires a 4.0 ET tube
• The Intubationist will then raise his/her right hand for you to place the ET tube into the right hand.
• Push the ET tube between the fingers of the Intubationist.
  • Remember, he/she is not looking up. If the intubationist has to take his/her eye off the target, your resuscitation will be inefficient.

• The ET tube is inserted to the desired depth.
  • 6 plus the weight of the infant in Kg. That’s the intubationist responsibility!
• The laryngoscope blade is then removed.
• The stylet is then removed if one is used.
• A CO2 detector is then placed on the end of the ET tube.
  • If you don’t have one handy, your resuscitation will be inefficient.
  • It comes out of the package all purple. When it turns gold, it indicates the presence of CO2. “Gold is Good.”

• Next, check for stomach gurgling during PPV.
• If epigastric gurgling is present this is a bad sign because the stomach was intubated. Take out the ET tube and try again.
• If you check the lung sounds before abdominal sounds, your resuscitation will be inefficient.
• Then check for bilateral breath sounds.
  • If you don’t check both sides, your resuscitation will be inefficient.

Using a stethoscope, check the neonates heart rate

• If the heart rate is less than 60 bpm, begin chest compression’s at a ration of 3 chest compression to 1 breath.
• Prepare for chest compression’s by:
  • Placing a 3-lead ECG on the infant’s chest. If you don’t use the 3-lead ECG, you may not get an accurate heart rate and your resuscitation will be inefficient.
• Increase the FiO2 to 100%
  • If you do not increase the FiO2 to 100%, your resuscitation will be inefficient.
• Chest compression’s and Ventilation’s are required with a 3:1 ratio.
  • Do 3 compression’s and then pause for 1 ventilation.
  • This cycle should take only 3 seconds.
  • If you do not do this rapidly, your resuscitation will be inefficient
• Compress the chest 1/3 the anterior to the posterior depth of the chest.
  • If you do not compress deeply, your resuscitation will be inefficient.
• Continue chest compression’s with ventilation’s for 60 seconds.
• Then check the heart rate again.
  • This can be accomplished with the 3-lead ECG.

If the heart remains less than 60 bpm, prepare for the administration Epinephrine.

• If you do not have Epinephrine ready, your resuscitation will be inefficient.
• The Endotracheal route is the route to be used initially.
  • It’s not the best way, but the fastest way.

• The dose for Epinephrine through the ET tube is:
  • 5 mg – 1.0 mg/kg
  • It may be easier for you to use the 0.5 mg/kg to determine the dose.
  • For a 3 kg infant, the dose would be 1.5 ml.
  • The dose is administered rapidly and PPV follows.
  • Wait 60 seconds to check the heart rate.
• Someone should be delegated to begin flushing the UVC.
  • Attach a stop-cock
  • If you don’t have a stop-cock handy, your resuscitation will be inefficient.
  • Flush with Normal Saline.

If the heart rate remains less than 60 bpm, the UVC is inserted just far enough the get blood return.

• The Epinephrine is then administered through the UVC.
• The dose of Epinephrine via the UVC is 0.1 mg/kg – 0.5 mg/kg
• It may be easier for you to use 0.1 mg/kg for the UVC access..
• For an infant weighing 1 kg the dose becomes 0.1 ml. (if you are using the 0.1 mg/kg dose.)
• Flush the UVC with normal saline.

• Wait 60 seconds and check the heart rate.
  • If you do not wait 60 seconds, you may be apt to repeat the Epinephrine too soon.

You may decide to give a fluid bolus of 10 ml/kg of body weight.

• This may be given via the UVC.
• A fluid bolus is given to increase fluid volume.
• You must administer this fluid volume with a slow push.
  • If you administer the fluid too rapidly, it will cause Intra-ventricular Hemorrhages, and you will compromise the infant.
• If the heart rate increases, you have been successful.
• Prepare to transfer to the NICU.
  • Be sure and use a preheated transfer isolette.
  • If you have not preheated your transfer isolette, your transfer will be compromised.
• Continue to provide PPV during the transport.
• Continue to provide O2 saturation during the transport.

Nurses Educational Opportunities offers the most recognized and stress free NRP skills course in Southern California. We offer a flexible course schedule for healthcare providers. You can be assured that if there is no class scheduled to meet your needs we will schedule an NRP skills course according to your available times. Click on the link below to view our current calendar and additional course information.

Click here to view NEO’s NRP Skills Schedule